Provider Demographics
NPI:1134165921
Name:MARTIN, AMANDA DEE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DEE
Last Name:MARTIN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2647 TRAVELERS WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-2475
Mailing Address - Country:US
Mailing Address - Phone:405-694-3444
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY PLZ
Practice Address - Street 2:MS 7000
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-4710
Practice Address - Country:US
Practice Address - Phone:573-986-6764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20060040892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer